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Continuity of Care

Standardizing Hospital Discharge Planning at the Mayo Clinic

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Background: Improving the quality of patient coordination in the transition from hospital to home is a high-priority health care concern. The Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation in the Medicare Program require that hospitals have a discharge planning (DP) process in effect that applies to all patients. The impact of a practice change in DP practice on the quality of care coordination at discharge was evaluated from patients' perspectives.

Methods: A multifactor, evidence-based DP practice change, which included merging of DP specialist roles and use of an early screen for DP decision support tool, was initiated in a large, Midwestern academic medical center and evaluated in a nonequivalent comparison group design with separate pre- and postpractice change samples. The three-item Care Transitions Measure™ (CTM-3™) was mailed to adults recently discharged from one medical and one surgical nursing unit before and after the practice change.

Results: Response rates were 52.4% before (218/416) and 39.5% (153/387) after the practice change. There were no significant differences between characteristics of the pre- and postpractice change participants. The mean CTM-3 score of patients who received assistance from the nurse/social worker DP team improved by 14 points (67.2 to 81.2), although the data were skewed with a ceiling effect, rendering the results inconclusive.

Conclusions: Although the CTM-3 results were inconclusive, the practice change resulted in a clinically meaningful decrease in length of stay for a group of older patients at greater risk for complex discharge plans. The proactive approach to DP proved to be a valuable shift. The successes of the standardization of DP processes and improved multidisciplinary teamwork were important considerations for implementation throughout the organization.

Document Type: Research Article

Publication date: January 1, 2011

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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